Monday, May 5, 2014

The Childhood Autism
Rating Scale, second edition (CARS 2), consists of two 15-item rating scales
completed by the practitioner and a Parent/Caregiver Questionnaire. The
Standard Version Rating Booklet (CARS 2-ST) is equivalent to the original CARS and
is used with children younger than 6 years of age and those with communication
difficulties or below-average cognitive ability. The High-Functioning Version
Rating Booklet (CARS 2-HF) is an alternative for assessing verbally fluent
children and youth, 6 years of age and older, with average or above
intellectual ability. The Questionnaire for Parents or Caregivers (CARS 2-QPC)
is an unscored questionnaire designed to obtain pertinent developmental
information from parents or caregivers.

The CARS 2-ST and CARS 2-HF each
include 15 items addressing the following functional areas:

Items on the Standard form
duplicate those on the original CARS, while items on the HF form have been
modified to reflect current research on the characteristics of higher
functioning children and youth with autism (HFA) or Asperger Syndrome. To
complete the ratings on the CARS 2-HF, the professional must have convergent
information from MULTIPLE sources such as direct observation, parent and
teacher interviews, prior assessments of cognitive functioning and adaptive
behavior, and information from the Questionnaire for Parents or Caregivers
(CARS 2-QPC). Ratings are based not only on frequency of the behavior in
question, but also on its intensity, atypicality, and duration. Rating values
for all items are summed to produce a Total Raw Score. Each form includes a
graph that allows the practitioner quickly convert the Total Raw Score to a
standard score or percentile rank (based on a clinical sample of individuals
diagnosed with autism spectrum disorders).

The psychometric
properties of the CARS 2-HF indicate a high degree of internal consistency and
good interrater reliability. Validity information reports an overall discrimination
index value of .93, with sensitivity and specificity values of .81 and .87,
respectively. The HF form also demonstrates a relatively strong relationship
with the “gold standard” Autism Diagnostic Observation Schedule (ADOS).

Preliminary research findings
suggest that a high proportion of individuals who meet the clinical cut-off for
autism on both the CARS-2-ST and CARS-2-HF meet the criteria for autism based on
both the DSM-IV-TR and DSM-5 (Dawkins, Meyer, & Van Bourgondien, 2014).

The following are critical
features of the CARS 2-HF.

1. Parents and teachers
should NOT be asked to complete the CARS 2 forms. Only well-informed
professionals should complete the ratings.

2. The CARS 2 should NOT
be used for screening in the general school-age population.

3. The practitioner must
have a good understanding of the criteria for making the ratings and be in a
position to collect information from multiple sources (direct observation,
parent and teacher reports, prior assessments and clinical impressions).

4. The ratings from the
CARS 2 should be considered as only one part of a multimodal, multidisciplinary
decision-making process in the identification of children with ASD.

5. Direct observation and
a developmental history MUST always be included in the assessment process.

6. Scores on the CARS 2
are interpreted relative to the level (severity) of autism-related behaviors
compared to a clinical sample of individuals diagnosed with autism, NOT the
typical individual.

In summary, The CARS 2-HF
represents an important alternative that will be welcomed by professionals such as school psychologists. It
is a sensitive and reliable instrument that will find a place in the
school-based professional’s assessment “Tool Box.” Given the dramatic increase
in the numbers of students being referred for screening and assessment, the
CARS 2-HF is a useful instrument that helps quantify the level of symptom
severity and importantly, assist with intervention and program planning. The
CARS 2-HF scores are particularly helpful in identifying more capable children
on the autism spectrum. Of course, the CARS 2 is not intended to be
and should not be used as the sole instrument in making diagnostic or
classification decisions. An example of a comprehensive assessment battery can
be found in A Best Practice Guide to Assessment and Intervention for Autism
Spectrum Disorder in Schools (2nd Edition).

1 comment:

Dear Dr. Wilkinson,Thank you for the timely and thorough review of the CARS2-HF. I particularly appreciate your emphasis on the CARS2 as only one part of a comprehensive assessment. In a world where "quick" is often valued more than valid, it is helpful to have one more voice supporting multi-modal, multi-disciplinary assessment!

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